Overview
Drug treatment for macular disease depends on the type: intravitreal anti-VEGF injections are the first-line standard for wet AMD and for myopic macular disease with neovascularisation; AREDS2 supplements slow the progression of dry forms at risk; control of risk factors (smoking, diet, blood pressure) is a universal preventive measure.
- Wet AMD and CNV
- Anti-VEGF injections — first-choice treatment, personalised schedule.
- Dry AMD at risk
- AREDS2 supplements — about 25% lower risk over 5 years, only in forms at risk.
- Myopic macular disease with CNV
- Anti-VEGF in the same way as for AMD — response generally very good.
- All forms
- Lifestyle: quit smoking, antioxidant diet, UV protection, regular check-ups.
Types of medicine
Four therapeutic groups, chosen according to the type of macular disease (wet or dry), the stage and the patient's risk factors. Anti-VEGF injections are the standard for the wet form; AREDS2 supplements and lifestyle support all forms.
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Intravitreal anti-VEGF injections
First choice for wet AMDThey block VEGF (Vascular Endothelial Growth Factor), the molecule that stimulates the growth of abnormal new blood vessels under the macula. They block choroidal neovascularisation (CNV), typical of wet AMD, and reduce oedema, bringing the retina back to a thickness closer to normal.
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Faricimab and brolucizumab — new generation
Less frequent injectionsNew-generation molecules designed to extend the interval between injections while maintaining clinical effectiveness. Faricimab is bispecific (it blocks VEGF and angiopoietin-2 at the same time); brolucizumab is an anti-VEGF with a lower molecular weight, which allows higher doses.
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AREDS2 supplements
Dry AMD at riskA combination of antioxidants and macular pigments that reduce oxidative stress on the macula. The AREDS and AREDS2 studies showed a reduction of about 25% in the risk of progression to the advanced form in patients with intermediate-to-large drusen or atrophy in one eye.
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Managing risk factors
Universal preventionEye treatments are not enough on their own without controlling the factors that fuel macular disease. Stopping smoking is the single most effective step; an antioxidant diet and control of blood pressure, weight and cholesterol significantly reduce the progression of all forms of macular disease.
Management and monitoring
The effectiveness of intravitreal injection therapy depends on a correct procedure in the operating theatre and on regular OCT check-ups. For AREDS2 supplements, the key is taking them consistently — a simple but essential daily habit.
The intravitreal injection procedure
The injection is given as an outpatient procedure, in the operating theatre, under topical anaesthesia (anaesthetic eye drops). It takes a few minutes and is generally well tolerated.
Topical anaesthesia with eye drops and thorough disinfection of the eye with iodine.
A small lid speculum keeps the eyelids open; the medicine is injected through the pars plana (4 mm from the limbus) with a very fine needle.
After the injection: antibiotic drops are put in and eye pressure is checked. Floaters or mild irritation may occur for a few hours.
In the following days avoid rubbing the eye and follow the centre's instructions on hygiene, make-up and swimming pools.
Monitoring with OCT
The success of treatment is assessed by visual acuity, the Amsler grid test at home and macular OCT at every check-up. OCT measures retinal thickness and the presence of fluid quantitatively — it is the main parameter for deciding whether to go ahead with the next injection.
OCT at every visit to measure macular thickness and the response to the medicine.
Treat & Extend schedule: if the OCT is dry, the interval is extended (usually by 2 weeks); if fluid appears, it is shortened.
Amsler grid test at home once a week — it is an early warning of abnormal new blood vessels becoming active between visits.
Tell your ophthalmologist straight away about sudden loss of vision, severe pain, marked redness or an increase in floaters.
Side effects
Intravitreal injections are generally safe and well tolerated. Side effects fall into two groups: frequent but mild local effects and serious but rare effects. AREDS2 supplements are well tolerated but require attention in certain groups of patients.
Frequent local effects of injections
A feeling of pressure or of something in the eye, floaters in the hours afterwards, mild redness of the conjunctiva, a small bleed under the conjunctiva. All of these are temporary symptoms that resolve within a few days.
Rare but serious effects of injections
Endophthalmitis (infection inside the eye) is the most feared complication: it is rare (1 in 1,000-3,000 injections) but requires urgent treatment. Other rare events include retinal detachment, severe vitreous haemorrhage and raised eye pressure. They present with severe pain, sudden loss of vision and marked redness.
AREDS2 supplements: considerations
Generally well tolerated. Caution is needed for people with gastric ulcers (high zinc content) and for smokers, for whom the original AREDS formula has been modified (beta-carotene replaced with lutein/zeaxanthin to reduce the risk of lung cancer). They never replace a healthy diet.
When to contact your ophthalmologist straight away
Severe eye pain, sudden loss of vision, marked redness, photophobia or a marked increase in floaters within 48-72 hours after an injection require an urgent eye examination. Likewise, new distortions on the Amsler grid test or dark spots in central vision require a prompt appointment — they may indicate reactivation of abnormal new blood vessels.